Consumer s Guide to Health Insurance Grievances and Complaints
|
|
- Shon Mosley
- 8 years ago
- Views:
Transcription
1 Consumer s Guide to Health Insurance Grievances and Complaints A Consumer s Guide to Resolving Disputes with Your Health Plan State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI OCI s Web Site: oci.wi.gov PI-217 (R 09/2015)
2 The mission of the Office of the Commissioner of Insurance... Leading the way in informing and protecting the public and responding to their insurance needs. If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, contact the Office of the Commissioner of Insurance (OCI). To file a complaint online or to print a complaint form: OCI s Web Site oci.wi.gov Phone (608) (In Madison) or (Statewide) Mailing Address Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI Electronic Mail ocicomplaints@wisconsin.gov Please indicate your name, phone number, and address. Deaf, hearing, or speech impaired callers may reach OCI through WI TRS This guide is not a legal analysis of your rights under any insurance policy or government program. Your insurance policy, program rules, Wisconsin law, federal law, and court decisions establish your rights. You may want to consult an attorney for legal guidance about your specific rights. The Office of the Commissioner of Insurance does not represent that the information in this publication is complete, accurate or timely in all instances. All information is subject to change on a regular basis, without notice. Publications are updated annually unless otherwise stated. Publications are available on OCI s Web site oci.wi.gov. If you need a printed copy of a publication, use the online order form or call One copy of this publication is available free of charge to the general public. All materials may be printed or copied without permission. 2
3 Introduction Most people will never have a problem with their health insurance. But when you do have a complaint with your plan, it can be difficult to understand the steps you must take to resolve your problem. This booklet serves as a guide to help you understand the grievance and complaint process that all policies sold in Wisconsin are required to offer you. The question and answer format allows you to read straight through, or go right to a particular question you may have. Also included at the end of the booklet is a series of worksheets that will help you to document your complaint process. It is important to remember that not all health plans are subject to the appeal process discussed in this booklet. If your plan is self-funded by your employer, then it is subject to federal, not state law. Public programs like Medicare and Medicaid also have their own processes. Make sure you are aware of what kind of health insurance plan you have before you begin the grievance process described in this booklet. What You Need to Know About Your Health Plan How do I receive medical benefits from my health plan? Most health plans require you to follow certain procedures in order to receive coverage from the plan. If you know the procedures your health plan requires and you follow them, you will less likely have problems when you do get sick. For example, you should know how to file a claim, when you might need prior authorization from your plan, when you need to contact the company, and who your in-network providers are. Familiarize yourself with these procedures before you need health care in order to minimize trouble when you are already dealing with health problems. Is your provider in-plan? If you are in a managed care plan, make sure your provider is in-plan before each visit to ensure you ll receive coverage. Some plans may have more than one benefit level; for example, specialists may require a different copay. Make sure you understand what you will be required to pay. You can verify this by checking the plan s Web site or by calling your insurer. What is covered and what is excluded under my health plan? You should be aware exactly what medical procedures and medications, etc., are covered under your plan in order to avoid planning a procedure that is not covered. You should review your summary of benefits and coverage for a quick overview, but your certificate of coverage will provide a complete picture. 3
4 What if my plan doesn t cover something? No health plan covers everything sometimes not even health care services that are medically necessary or procedures where there is no other option. However, remember that as a consumer you can ask your insurer to cover your procedure if you believe that it is an effective treatment. You can ask that the insurer consider covering the procedure on an exception basis if you believe that it is more effective than a covered procedure. Where do I find answers to these questions? Review your member material, including your policy and your certificate. Your plan s summary of benefits and coverage can provide a quick overview of plan benefits. For coverage of Rx drugs, check your plan s formulary. You can also call your health plan s customer service number or check their Web site for this information. If your plan is employer based, you can talk to your employer s human resources section to find answers. Most importantly, make sure to keep all records. This includes your policy certificate and other member materials, any correspondence from your insurer, letters from providers and/or other documents such as medical records and test results, and also records of all phone calls made to your health plan. The attached worksheets are included to help you document conversations with your insurer. What if coverage is denied? If your plan denies your claim or your request for coverage, you will receive a written notice. This denial notice (or explanation of benefits) should explain why your insurer denied your claim. Your health plan should give you a specific reason for the denial. The notice should also explain your appeal rights. What should I do if I have a complaint? Many complaints or questions can be resolved informally by calling your plan s customer service line. Many health plans also have Web sites that can be helpful in resolving your complaints. If you have questions regarding how to complain to your insurer, call OCI at or visit oci.wi.gov for help filing a complaint. Make sure to keep all records. This includes your policy certificate and other member materials, any correspondence from your insurer, letters from providers and/or other documents such as medical records and test results, and also records of all phone calls made to your health plan. What if I m not satisfied with the results of my complaint? You still have the right to file a grievance. Your denial notice may explain how to do this, or it will tell you how to find these instructions. The denial notice also includes information about your right to have your claim reviewed by an Independent Review Organization. 4
5 What is a grievance? A grievance is any written dissatisfaction with the provision of services, claims practices, or the administration of a health benefit plan. A grievance may be submitted by you or you may authorize someone to submit the grievance on your behalf. For example, a grievance can be filed when your health plan denies your request for a referral, your health plan will not cover a treatment you believe you need, or the quality of your treatment is lacking. In some cases, you may need to resolve your grievance more quickly than the standard grievance process. If this is the case, request an expedited grievance. An expedited grievance means a grievance where any of the following apply: The length of time for a normal grievance resolution would result in serious jeopardy to your life or health or would limit the ability for you to regain maximum function. Your physician requests the expedited process because your pain is too severe to be adequately managed without the care or treatment that you are requesting. Your physician determines that the grievance should be treated as an expedited grievance. How do I file a grievance with my health plan? You may file a grievance by sending a letter to your health plan. Keep the following points in mind when writing and sending your letter: Identify yourself, including your name, address, and health plan ID number. Explain the problem; be specific with dates of service, denial notice, summaries of any phone conversations, and why you believe the plan s decision is wrong. Base your argument on policy language; if you are asking for an exception, explain how coverage could benefit the plan such as avoiding a more expensive treatment that is covered. Clearly state what you want the resolution of your grievance to be. Include photocopies of any supporting documents, such as medical records, referrals, supporting letters from doctors, and articles from peer-reviewed medical journals. If your grievance involves a medical issue, you may want to talk to a doctor and ask if he/she has any records that may support your position. Keep the letter business-like. 5
6 If someone else is sending the grievance for you, include a note signed by you authorizing that person to act on your behalf; most plans will require this. Send the letter to the address provided on the denial notice or in your certificate. What happens next? Your health plan must send you an acknowledgment within five business days of receiving your letter. If you do not receive an acknowledgment, call your plan. Some plans may review the grievance to try to resolve the problem informally. Can I be present at the grievance review? Yes, but you are not required to attend. Your health plan must send you a notice of the time and place of the meeting at least seven days in advance. You have the right to appear in person or by teleconference before the grievance panel where you may present written and oral information and question the decision makers. The grievance panel must include at least one individual authorized to take corrective action, one insured who is not part of the plan, if possible, and may not include the person who made the initial determination. The panel is not required to include a medical professional but should consult one when appropriate. When can I expect to hear from my health plan? Your plan should send you a grievance resolution letter within 30 days of initially receiving the grievance. They may also choose to extend the decision another 30 days but must send you a written notice explaining the reason for the extension. When you do receive a response, it will be in the form of a letter that will either accept or deny your grievance. If your grievance was denied, the letter should explain any additional options, including the right to an independent review. The letter should be signed by one voting member of the panel and include the titles of the panel members. Independent Review Process Both state and federal law give individuals the right to request an independent external review when their health plan denies or reduces coverage of medical services in some circumstances. Although the laws are similar, there are some significant differences. This booklet provides general information on the state process. 6
7 What is an independent review? An independent review is a process that allows an outside expert to provide a second look at your claim. Because the reviewer is not affiliated with you, your medical provider, or the insurer, the reviewer is able to conduct an independent and unbiased review of your claim. The independent review process is intended to be an easy way to allow you to receive an independent decision within a relatively short time frame. You can request an independent review whenever your health plan denies you coverage for treatment based on a medical judgment. For example, you may request an independent review if the health plan maintains that the treatment is not medically necessary according to their definition, or that the treatment is experimental. You may not request an independent review if the requested treatment is not a covered benefit in your health plan. Who performs the independent review? The independent review process provides you with an opportunity to have your dispute reviewed by experts who have no connection to you, your medical provider, or your health plan. The independent review organization (IRO) assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The clinical peer reviewer is generally a board-certified physician or other appropriate medical professional. In some cases, the IRO will also consult with an attorney or other insurance expert. When can I request an independent review? You can request an independent review whenever your insurer bases its decision to deny coverage on a medical judgment. In most cases you cannot request independent review until you have completed the internal grievance process, but you may bypass this process if both you and the insurer agree or the IRO agrees that a delay in receiving care could jeopardize your health. The independent review must be requested within four months of the date listed on your grievance resolution letter. How do I request an independent review? The grievance resolution letter should explain how to request an independent review. Send your request for an independent review to the address provided in the insurer s final written decision letter. Be sure to include: your name, address, and phone number an explanation of why you believe that the treatment should be covered any additional information or documentation that supports your position (photocopies) if someone else is filing on your behalf, a statement signed by you authorizing that person to be your representative any other information requested by your insurer 7
8 After your insurer receives the information, they must send all relevant medical records and other documentation used in making its decision to the IRO within five business days. The IRO then has five business days to review the information and to request any additional information it may need from the insurer or from you. Then what will the IRO do? First the IRO will review the request to verify it has no connection to the insurer or health care provider. Then the IRO will review the file to determine if it is complete. You or your insurer may be asked for additional information. When the IRO has all the information it needs, it has 30 business days to make a decision. The file is forwarded to a clinical peer reviewer who has relevant expertise. In reviewing a case involving medical necessity, the IRO and its reviewer are required to consider all of the documentation, including your medical records, your attending provider s recommendation, the terms of coverage of your health plan, the rationale for the insurer s prior decision, and any medical or scientific evidence. It must limit its decision on a case involving experimental treatment to whether the proposed treatment is experimental. After 30 days, the IRO will send its decision letter to you and your insurer. Federal external review process: Most health plans in Wisconsin are required to follow the federal external review process. Under the federal process, insurance companies may choose to participate in either an external review process administered by the U.S. Department of Health and Humans Services (HHS) or to follow the external review process regulations developed by the U.S. Department of Labor (DOL). HHS has contracted with Maximus Federal Services, Inc., to provide independent external reviews under the HHS-administered process. Information on this process is available at externalappeal.com/ or by calling Health plans that choose to follow the DOL external review process must privately contract with at least three nationally accredited independent review organizations. You send your review request to the health plan. It must have a process to randomly choose one of its contracted IROs when it receives a request for an external review. What if I need medical attention now? If you believe you need treatment urgently and that waiting the 30 days for the IRO to complete the standard independent review process could jeopardize your health or life, you may be eligible for an expedited process. Send your request to both your insurer and the IRO at the same time. The IRO s medical staff will then review your request and has the authority to determine if the grievance process may be bypassed. You will be given a decision in 72 hours or as soon as your health condition requires. 8
9 Do I have any other options? If you have already gone through the grievance process and still are unsatisfied with the results you can: File a complaint with OCI. Contact the Managed Care Specialist at OCI who will answer questions about your rights and responsibilities, including your right to file a grievance and to an independent review. The Specialist can also assist in urgent situations. Hire an attorney. Take your complaint to small claims court. Your employer may have insurance experts that might be able to help. It may also be beneficial to contact the Department of Labor, the Centers for Medicare and Medicaid Services, or the Department of Health Services for help with your complaint. Employer self-funded complaints: Other Resources The U.S. Department of Labor regulates employer self-funded health plans. You can file a complaint or submit a question by contacting them at consumerassistance.html or by calling their toll-free number
10 Step 1: Get to know your health plan Grievance and Complaints Worksheet Company name: Company address: Company phone number: My health plan is through: address city state zip code [ ] My employer [ ] A policy I bought myself [ ] An association-sponsored policy (such as through a trade, civic or educational organization) [ ] Other: What is covered under my health plan: [ ] Are the doctors, hospitals and other medical providers that I use in the plan s network? [ ] If I choose to use a doctor outside the provider s network will I be covered? [ ] Can I change my primary-care physician if I want to? 10
11 [ ] Do I need to get permission before seeing a medical specialist? [ ] What are the procedures for getting care and being reimbursed in an emergency, both at home and out of town? [ ] If I have a chronic medical condition, how will the plan treat it? [ ] Are my prescription medications covered by my health plan? [ ] If I want alternative medical therapies such as acupuncture or chiropractic treatment, will they be covered by my health plan? [ ] Are all pregnancy-related medical costs covered by the provider? 11
12 Step 2: Keep your records In an event that you may have a complaint in the future, it is important to keep all records relating to your insurance policy. [ ] Policy certificate [ ] Medical records/test results [ ] Letters from providers [ ] Records of all phone conversations, including Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): 12
13 Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): 13
14 Step 3: Write your letter Make sure you use the following tips when writing your complaint letter: [ ] Did I include my name, address, phone number and my policy ID number? [ ] Did I fully explain the problem, including: [ ] dates of service? [ ] summaries of phone conversations? [ ] reasons I believe the plan s decision is wrong? [ ] Did I use policy language? [ ] Did I clearly state my intended resolution? [ ] Did I include photocopies of all supporting documents? [ ] If someone else is sending the grievance on my behalf, did I include a note signed by me? [ ] Did I send the letter to the address provided on the denial notice? 14
HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER
CONSUMER'SGUIDE A Consumer s Guide to HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER from your North Carolina Department of Insurance A MESSAGE
More informationMedicare Supplement Insurance Approved Policies 2011
Medicare Supplement Insurance Approved Policies 2011 For more information on health insurance call: MEDIGAP HELPLINE 1-800-242-1060 This is a statewide toll-free number set up by the Wisconsin Board on
More informationWhat Happens When Your Health Insurance Carrier Says NO
* What Happens When Your Health Insurance Carrier Says NO Most health carriers today carefully evaluate requests to see a specialist or have certain medical procedures performed. A medical professional
More informationMedical and Rx Claims Procedures
This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers
More informationExternal Review Request Form
External Review Request Form This EXTERNAL REVIEW REQUEST FORM must be filed with the Nebraska Department of Insurance within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a
More information005. Independent Review Organization External Review Annual Report Form
Title 210 NEBRASKA DEPARTMENT OF INSURANCE Chapter 87 HEALTH CARRIER EXTERNAL REVIEW 001. Authority This regulation is adopted by the director pursuant to the authority in Neb. Rev. Stat. 44-1305 (1)(c),
More informationAppeals: Eligibility & Health Plan Decisions in the Health Insurance Marketplace
Appeals: Eligibility & Health Plan Decisions in the Health Insurance Marketplace There are 2 kinds of appeals you can make once you ve applied and enrolled in coverage through the Health Insurance Marketplace:
More informationServices Available to Members Complaints & Appeals
Services Available to Members Complaints & Appeals Blue Cross and Blue Shield of Texas (BCBSTX) resolves complaints and appeals related to any aspect of service provided by itself or any subcontractor
More informationUnderstanding Annuities
This guide: Explains the different types of annuity contracts Describes the various contractual features Discusses how to shop for an annuity State of Wisconsin Office of the Commissioner of Insurance
More informationHow to Request an Exception or Appeal a Decision From Your Prescription Drug Plan
How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan Exceptions What is an Exception? Sometimes you may not be able to obtain a prescription medication that your healthcare
More informationUnderstanding Annuities
This guide: Explains the different types of annuity contracts Describes the various contractual features Discusses how to shop for an annuity State of Wisconsin Office of the Commissioner of Insurance
More informationState of Wisconsin / OFFICE OF THE COMMISSIONER OF INSURANCE
State of Wisconsin / OFFICE OF THE COMMISSIONER OF INSURANCE Scott Walker, Governor Theodore K. Nickel, Commissioner Wisconsin.gov 125 South Webster Street P.O. Box 7873 Madison, Wisconsin 53707-7873 Phone:
More informationSTAR/Medicaid Member Complaint and Appeals Process
STAR/Medicaid Member Complaint and Appeals Process What should I do if I have a complaint? We want to help. If you have a complaint, please call us toll-free at 1-855-526-7388 to tell us about your problem.
More informationCovered Person/Applicant Authorized Representative (please complete the Appointment of Authorized Representative section)
REQUEST FOR EXTERNAL REVIEW Instructions 1. If you are eligible and have completed the appeal process, you may request an external review of the denial by an External Review Organization (ERO). ERO reviews
More informationA Consumer s Guide to Internal Appeals and External Reviews
A Consumer s Guide to Internal Appeals and External Reviews The Iowa Insurance Division, Consumer Advocate Bureau http://www.insuranceca.iowa.gov June 2012 Table of Contents Introduction Page 3 Chapter
More informationHaving health insurance is a
Fully-Insured and Issued in New Jersey Having health insurance is a good thing, and health insurers usually do what they re supposed to do. They authorize coverage for services that are medically necessary
More informationEXTERNAL REVIEW CONSUMER GUIDE
EXTERNAL REVIEW CONSUMER GUIDE STATE OF CONNECTICUT INSURANCE DEPARTMENT Rev. 7-11 CONNECTICUT INSURANCE DEPARTMENT EXTERNAL REVIEW CONSUMER GUIDE OVERVIEW Connecticut Public Act 11-58 gives you the right
More informationCALIFORNIA: A CONSUMER S STEP-BY-STEP GUIDE TO NAVIGATING THE INSURANCE APPEALS PROCESS
Loyola Law School Public Interest Law Center 800 S. Figueroa Street, Suite 1120 Los Angeles, CA 90017 Direct Line: 866-THE-CLRC (866-843-2572) Fax: 213-736-1428 TDD: 213-736-8310 E-mail: CLRC@LLS.edu www.cancerlegalresourcecenter.org
More informationA CONSUMER GUIDE TO HANDLING DISPUTES WITH YOUR PRIVATE OR EMPLOYER HEALTH PLAN
A CONSUMER GUIDE TO HANDLING DISPUTES WITH YOUR PRIVATE OR EMPLOYER HEALTH PLAN Prepared by: Trudy Lieberman, Director Center for Consumer Health Choices Consumers Union Elizabeth Peppe Consultant to the
More informationHealth Care Insurer Appeals Process Information Packet
{PAGE} Health Care Insurer Appeals Process Information Packet CAREFULLY READ THE INFORMATION IN THIS PACKET AND KEEP IT FOR FUTURE REFERENCE. IT HAS IMPORTANT INFORMATION ABOUT HOW TO APPEAL DECISIONS
More informationManaged Care 101. What is Managed Care?
Managed Care 101 What is Managed Care? Managed care is a system to provide health care that controls how health care services are delivered and paid. Managed care has grown quickly because it offers a
More informationWisconsin Guide to Health Insurance for People with Medicare
Wisconsin Guide to Health Insurance for People with Medicare 2015 For more information on health insurance call: MEDIGAP HELPLINE 1-800-242-1060 This is a statewide toll-free number set up by the Wisconsin
More information? If your problem is about decisions related to benefits,
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 188 MAKING COMPLAINTS SECTION 10 How to make a complaint about quality of care, waiting times, customer
More informationUtilization Management
Utilization Management L.A. Care Health Plan Please read carefully. How to contact health plan staff if you have questions about Utilization Management issues When L.A. Care makes a decision to approve
More informationUsing Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered
Using Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered SPRING 2009 9 www.yourpharmacybenefit.org Table of Contents How does it work?............................................ 1 When
More informationAetna Life Insurance Company
Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment (GR-GrpAppealsER 03) Policyholder: Group Policy No.: Effective Date: GP- This Amendment is effective on the later of: July 12, 2012; or
More informationGuide to Appeals. 30 Winter Street, Suite 1004, Boston, MA 02108 Phone +1 617-338-5241 Fax +1 617-338-5242 www.healthlawadvocates.
Guide to Appeals 30 Winter Street, Suite 1004, Boston, MA 02108 Phone +1 617-338-5241 Fax +1 617-338-5242 www.healthlawadvocates.org This guide was made possible by funding from the Commonwealth Health
More informationWisconsin Guide to Health Insurance for People with Medicare
Wisconsin Guide to Health Insurance for People with Medicare 2015 For more information on health insurance call: MEDIGAP HELPLINE 1-800-242-1060 This is a statewide toll-free number set up by the Wisconsin
More informationVI. Appeals, Complaints & Grievances
A. Definition of Terms In compliance with State requirements, ValueOptions defines the following terms related to Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial
More informationConsumer's Guide to. Managed Care Health Plans. In Wisconsin
Consumer's Guide to Managed Care Plans In Wisconsin State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI 53707-7873 OCI's Web Site: oci.wi.gov PI-044 (R 09/2015) The mission
More informationHealth Insurance For Small Employers and Their Employees 2011
Health Insurance For Small Employers and Their Employees 2011 State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI 53707-7873 oci.wi.gov PI-206 (R 12/2010) Health Insurance
More informationThe Health Insurance Marketplace: Know Your Rights
The Health Insurance Marketplace: Know Your Rights You have certain rights when you enroll in a Marketplace health plan. These rights include: Getting easy-to-understand information about what your plan
More informationA PATIENT S GUIDE TO. Navigating the Insurance Appeals Process
A PATIENT S GUIDE TO Navigating the Insurance Appeals Process Dealing with an injury or illness is a stressful time for any patient as well as for their family members. This publication has been created
More informationAppeals Provider Manual 15
Table of Contents Overview... 15.1 Commercial Member appeals... 15.1 Self-insured groups... 15.1 Traditional/CMM Members... 15.1 Who may appeal... 15.1 How to file an internal appeal on behalf of the Member...
More informationHow To Appeal A Health Insurance Claim
INTRODUCTION Most people now get their health care through some form of managed care plan a health maintenance organization (HMO), 1 preferred provider organization (PPO), 2 or point-of-service plan (POS).
More informationHow To Appeal An Adverse Benefit Determination In Aetna
Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment Policyholder: Group Policy No.: Effective Date: University Of Pennsylvania Postdoctoral Insurance Plan GP-861472 This Amendment is effective
More informationMedicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal) Medicare Advantage Plans (like an HMO or PPO) and Medicare Cost
More informationGetting Medi-Cal Outpatient Specialty Mental Health Services
California s Protection & Advocacy System Toll-Free (800) 776-5746 Getting Medi-Cal Outpatient Specialty Mental Health Services August 2010, Pub #5084.01 I was told that I need Medi-Cal specialty mental
More informationCOMPLAINT AND GRIEVANCE PROCESS
COMPLAINT AND GRIEVANCE PROCESS The complaint and grievance process for fully insured employer groups may differ from the standard complaint and grievance process for self-insured groups. Always check
More informationHow To Get A Life Insurance Plan In Awi.Com
Health Insurance for Small Employers and Their Employees 2015 State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI 53707-7873 oci.wi.gov PI-206 (R 06/2015) Health Insurance
More informationNH Medicaid Managed Care Supplemental Issue
Empowering and informing families and professionals caring for children with special health care needs and disabilities from birth to adulthood. NH Medicaid Managed Care Supplemental Issue In 2011 the
More informationYour Health Care Benefit Program. BlueAdvantage Entrepreneur Participating Provider Option
Your Health Care Benefit Program BlueAdvantage Entrepreneur Participating Provider Option GROUP CERTIFICATE RIDER Changes in state or federal law or regulations or interpretations thereof may change the
More informationMember Rights, Complaints and Appeals/Grievances 5.0
Member Rights, Complaints and Appeals/Grievances 5.0 5.1 Referring Members for Assistance The Member Services Department has representatives to assist with calls for: General verification of member eligibility
More informationMedicare Supplement Insurance Approved Policies List 2015
Medicare Supplement Insurance Approved Policies List 2015 For more information on health insurance call: MEDIGAP HELPLINE 1-800-242-1060 This is a statewide toll-free number set up by the Wisconsin Board
More informationHow to make a complaint about quality of care, waiting times, customer service, or other concerns
SECTION 10 Section 10.1 How to make a complaint about quality of care, waiting times, customer service, or other concerns What kinds of problems are handled by the complaint process? This section explains
More informationGetting the Medications and Treatments You Need
Neuropathy Action Foundation Awareness Education Empowerment Getting the Medications and Treatments You Need Understanding Your Rights in Arizona As you search for a health insurance plan or coverage for
More informationAppealing a coverage decision made by your Medical Assistance plan
Appealing a coverage decision made by your Medical Assistance plan A Guide to Grievances, Complaints, and Fair Hearings in Pennsylvania s Medical Assistance Program. Prepared by: The Pennsylvania Health
More informationSick & In Debt Handling Medical Debt
Sick & In Debt Handling Medical Debt 2007 CAA Forum September 7, 2007 Overview What to do when a client has a medical bill? Medi-Cal Defenses & Reimbursement Defenses for Enrollees of Managed Care Plans
More informationMaking it happen HOW TO ACCESS BEHAVIORAL HEALTH TREATMENT SERVICES FROM PRIVATE HEALTH INSURANCE FOR INDIVIDUALS WITH AUTISM A GUIDE FOR PARENTS
Making it happen HOW TO ACCESS BEHAVIORAL HEALTH TREATMENT SERVICES FROM PRIVATE HEALTH INSURANCE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS A GUIDE FOR PARENTS SECTION 1 SECTION 2 SECTION 3 SECTION
More informationThe Appeals Process For Medical Billing
The Appeals Process For Medical Billing Steven M. Verno Professor, Medical Coding and Billing What is an Appeal? An appeal is a legal process where you are asking the insurance company to review it s adverse
More informationAetna Life Insurance Company Hartford, Connecticut 06156
Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment Customer Trinity University Agreement No. 2 Amendment Complaint and Appeals Health Amendment Issue Date July 16, 2009 Effective Date June
More informationAetna Life Insurance Company Hartford, Connecticut 06156
Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment (GR-9N-Appeals 01-01 01) Policyholder The TLC Companies Group Policy No. GP-811431 Rider Arizona Complaint and Appeals Health Rider Issue
More informationOutline of Coverage. Medicare Supplement
Outline of Coverage Medicare Supplement 2015 Security Health Plan of Wisconsin, Inc. Medicare Supplement Outline of Coverage Medicare Supplement policy The Wisconsin Insurance Commissioner has set standards
More informationMember Guide. Combined Evidence of Coverage & Disclosure Form 2013. Healthy San Diego. Your Managed Medi-Cal Plan
Member Guide Combined Evidence of Coverage & Disclosure Form 2013 Healthy San Diego Your Managed Medi-Cal Plan Corporate Office 2420 Fenton Street, Suite 100 Chula Vista, CA 91914 1-800-224-7766 Important
More informationWhat is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/cuhealthplan or by calling 1-800-735-6072.
More informationMedicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal Medicare offers insurance coverage for prescription drugs through
More informationMedicare Advantage HMOs
Medicare Advantage HMOs Medicare Advantage HMOs are managed care plans that have contracts with Medicare. These HMOs are also called MA HMOs. If you are in one, you will get your Medicare services through
More informationThe Health Insurance Marketplace: Know Your Rights
The Health Insurance Marketplace: Know Your Rights You have certain rights when you enroll in a health plan in the Marketplace. These rights include: Getting easy-to-understand information about what your
More informationPremera Blue Cross Medicare Advantage Provider Reference Manual
Premera Blue Cross Medicare Advantage Provider Reference Manual Introduction to Premera Blue Cross Medicare Advantage Plans Premera Blue Cross offers Medicare Advantage (MA) plans in King, Pierce, Snohomish,
More informationA BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR
HOUSE BILL NO. INTRODUCED BY G. MACLAREN BY REQUEST OF THE STATE AUDITOR 0 A BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR UTILIZATION REVIEW, GRIEVANCE, AND EXTERNAL
More informationNEW YORK STATE EXTERNAL APPEAL
NEW YORK STATE EXTERNAL APPEAL You have the right to appeal to the Department of Financial Services (DFS) when your insurer or HMO denies health care services as not medically necessary, experimental/investigational
More informationFIDUCIARY UNDERSTANDING YOUR RESPONSIBILITIES UNDER A GROUP HEALTH PLAN. Health Insurance Cooperative Agency www.hicinsur.com 913.649.
UNDERSTANDING YOUR FIDUCIARY RESPONSIBILITIES UNDER A GROUP HEALTH PLAN Health Insurance Cooperative Agency www.hicinsur.com 913.649.5500 1 Content Introduction The essential elements of a group health
More informationYour Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Options Plus HMO SNP
January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Options Plus HMO SNP This booklet gives you the
More informationOUTLINE OF MEDICARE SUPPLEMENT COVERAGE BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JUNE 1, 2010
A Medicare Supplement Program An independent licensee of the Blue Cross and Blue Shield Association. This chart shows the benefits included in each of the standard Medicare supplement plans. Every company
More informationYour Pharmacy Benefit: Make it Work for You!
Your Pharmacy Benefit: Make it Work for You! www.yourpharmacybenefit.org Table of Contents Choose Your Plan.............................................2 Steps in Choosing Your Pharmacy Benefits.........................
More informationHow To Contact Us
Molina Medicare Options Plus HMO SNP Member Services Method Member Services Contact Information CALL (800) 665-1029 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time. Member Services
More informationChapter 15 Claim Disputes and Member Appeals
15 Claim Disputes and Member Appeals CLAIM DISPUTE AND STATE FAIR HEARING PROCESS (FOR PROVIDERS) Health Choice Arizona processes provider Claim Disputes and State Fair Hearings in accordance with established
More informationThe Health Insurance Marketplace: Know Your Rights
The Health Insurance Marketplace: Know Your Rights You have certain rights when you enroll in a health plan in the Marketplace. These rights include: Getting easy-to-understand information about what your
More informationHow to Appeal a Health Care Insurance Decision
How to Appeal a Health Care Insurance Decision A Guide for Consumers in Washington State August 2011 Version 4.0 Produced by: www.insurance.wa.gov With funds provided by The Affordable Care Act and administered
More informationConsumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
ConneCtiCut insurance DePARtMent Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
More information2016 Provider Directory. Commercial Unity Prime Network
2016 Provider Directory Commercial Unity Prime Network TM IMPORTANT CONTACT INFORMATION Read the instructions for using this network and then complete this page after you have selected Primary Care Physicians
More informationYou can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pekininsurance.com or by calling 1-800-371-9622. Important
More informationGLEEVEC PATIENT ASSISTANCE PROGRAM USA Patient Guide. Joan D. Ramos, MSW Cancer Resources & Advocacy Seattle, WA
GLEEVEC PATIENT ASSISTANCE PROGRAM USA Patient Guide Joan D. Ramos, MSW Cancer Resources & Advocacy Seattle, WA This guide is for informational purposes only and does not constitute legal or medical advice.
More informationPatient Assistance Resource Center Health Insurance Appeal Guide 03/14
Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its
More informationHEALTH INSURANCE APPEALS
Your Guide to filing HEALTH INSURANCE APPEALS Sometimes a health plan will make a decision that you disagree with. The plan may deny your application for coverage, determine that the healthcare services
More informationThe Pennsylvania Insurance Department s. Your Guide to filing HEALTH INSURANCE APPEALS
Your Guide to filing HEALTH INSURANCE APPEALS Sometimes a health plan will make a decision that you disagree with. The plan may deny your application for coverage, determine that the healthcare services
More informationWorkers' Compensation in California: Questions & Answers
Workers' Compensation in California: Questions & Answers prepared for the California Commission on Health and Safety and Workers' Compensation October 2006 Page 2 Introduction. How To Use This Booklet.....................................
More informationOutline of Coverage. Medicare Supplement
Outline of Coverage Medicare Supplement 2016 Security Health Plan of Wisconsin, Inc. Medicare Supplement Outline of Coverage Medicare Supplement policy The Wisconsin Insurance Commissioner has set standards
More informationAppeals and Provider Dispute Resolution
Appeals and Provider Dispute Resolution There are two distinct processes related to Non-Coverage (Adverse) Determinations (NCD) regarding requests for services or payment: (1) Appeals and (2) Provider
More informationTexas Health Care Network. Employee Notification Packet
Texas Health Care Network Employee Notification Packet 93681/0897C (Rev 10/13) Contents Employee Notification of Workers Compensation Health Care Network 2 Acknowledgement Form 5 AIG Texas Health Care
More information9. Claims and Appeals Procedure
9. Claims and Appeals Procedure Complaints, Expedited Appeals and Grievances Under Empire s Hospital Benefits or Retiree Health Benefits Plan Complaints If Empire denies a claim, wholly or partly, you
More informationConsumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
CONNECTICUT INSURANCE DEPARTMENT Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
More informationElderCare Medicare Health Plan Analyzer
ElderCare Medicare Health nalyzer 1999 Prism Innovations, Inc. All Rights Reserved ElderCare Medicare Health nalyzer Table of Contents Introduction 2 Explanations of New Health Plan Options 3 Analysis
More informationMagellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP)
Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP) 2014 Magellan Health Services Table of Contents SECTION 1: INTRODUCTION... 3 Welcome... 3 Covered
More informationIntroduction and Overview of HCO Program
Introduction and Overview of HCO Program To meet the requirements of Article 8 9771.70, First Health has designed this manual for The First Health Network providers participating in The First Health/CompAmerica
More informationCENTERS FOR MEDICARE & MEDICAID SERVICES. Medicare Appeals
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Appeals This official government booklet has important information about: How to file an appeal if you have Original Medicare How to file an appeal if
More informationEnclosed is information to help guide you through the Part D appeals process.
Date: Dear Helpline Caller: The Medicare Rights Center is a national, nonprofit organization. We help older adults and people with disabilities with their Medicare problems. We support caregivers and train
More informationEarly Start Program. A Guide to Health Insurance For Parents of Children from Birth to 3 Years with Developmental Delays
Early Start Program A Guide to Health Insurance For Parents of Children from Birth to 3 Years with Developmental Delays 1 TABLE OF CONTENTS INTRODUCTION 4 Why did I get this booklet and why is it important?
More informationWisconsin typically ranks among the states with the highest level of health
Health Insurance Marketplace in Wisconsin by Wisconsin Office of the Commissioner of Insurance Staff Wisconsin typically ranks among the states with the highest level of health care coverage for its citizens.
More information2016 Evidence of Coverage for Passport Advantage
2016 Evidence of Coverage for Passport Advantage EVIDENCE OF COVERAGE January 1, 2016 - December 31, 2016 Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Passport
More informationMember Handbook A brief guide to your health care coverage
Member Handbook A brief guide to your health care coverage Preferred Provider Organization Plan Using the Private Healthcare Systems Network PREFERRED PROVIDER ORGANIZATION (PPO) PLAN USING THE PRIVATE
More informationFrequently Asked Questions About Your Hospital Bills
Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of
More informationPrivate Health Insurance and HMOs
Private Health Insurance and HMOs Jodi Hanna, Attorney Wisconsin Coalition for Advocacy Health insurance coverage in Wisconsin Introduction Maintaining health insurance coverage can be an important means
More informationEvidence of Coverage:
January 1 December 31, 2014 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of First Choice VIP Care (HMO-SNP) This booklet gives you the details
More informationTIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS
ADMINISTRATIVE POLICY TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS Policy Number: ADMINISTRATIVE 088.15 T0 Effective Date: November 1, 2015 Table of Contents APPLICABLE LINES OF
More informationA Consumer s Guide to Appealing Health Insurance Denials
STATE OF CONNECTICUT Insurance Department Appeals & External Review Guide RIGHTS GUIDANCE APPEAL ASSISTANCE October 2013 A Consumer s Guide to Appealing Health Insurance Denials Introduction This guide
More informationREQUEST FOR INDEPENDENT EXTERNAL REVIEW OF A HEALTH INSURANCE GRIEVANCE THROUGH THE OFFICE OF PATIENT PROTECTION
The Commonwealth of Massachusetts Health Policy Commission Office of Patient Protection 50 Milk Street, 8 th Floor Boston, MA 02109 (800)436-7757 (phone) (617)624-5046 (fax) REQUEST FOR INDEPENDENT EXTERNAL
More informationifuse Implant System Patient Appeal Guide
ifuse Implant System Patient Appeal Guide Table of Contents PURPOSE OF THIS BOOKLET...................................................... 2 GUIDE TO THE APPEALS PROCESS..................................................
More informationConsumer Assistance and Outreach Services
Consumer Assistance and Outreach Services We are here to help you! Commonwealth of Virginia State Corporation Commission Bureau of Insurance Consumer Assistance Services The State Corporation Commission
More informationXXXXX Petitioner v File No. 121439-001. Issued and entered this 27 TH day of October 2011 by R. Kevin Clinton Commissioner ORDER
In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX Petitioner
More information